Provider Demographics
NPI:1871020602
Name:GREATER BUFFALO UNITED ACCOUNTABLE CARE ORGANIZATION,LLC
Entity Type:Organization
Organization Name:GREATER BUFFALO UNITED ACCOUNTABLE CARE ORGANIZATION,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-830-4840
Mailing Address - Street 1:229 W GENESEE ST
Mailing Address - Street 2:PO BOX 877
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-7099
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:564 NIAGARA ST
Practice Address - Street 2:REAR
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1108
Practice Address - Country:US
Practice Address - Phone:716-247-5282
Practice Address - Fax:716-884-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty